The Cambridge Health Alliance Center for Multicultural Health Research delivered the Right Question Project – Mental Health (RQP-MH) intervention, with minority patients receiving mental health services. This intervention included a Question Formulation Technique (QFT) and a Framework for Accountable Decision-Making (FADM), two techniques developed by the Right Question Institute. The RQP-MH intervention aimed to improve patient-provider interactions and to increase patient involvement and decision making, by building patients’ skills to obtain information from providers, clarify expectations of treatment, and become active participants in care. This study implemented RQP-MH in a three-pronged approach:

RQP-MH Coaching to Care Managers

RQP-MH Trainings for Patients

Treatment Adherence and Fidelity Checks

After adjusting for age, sex, race/ethnicity, and education, intervention subjects were over three times more likely to be retained in treatment than comparison patients. In terms of engagement, intervention patients were over four times more likely to be engaged in care than comparison patients. When assessing the intensity of visits for having at least one visit, intervention subjects were 28% more likely to be engaged in treatment than comparison patients.

This article explores the qualitative data from the Cambridge Health Alliance Center for Multicultural and Mental Health Research study summarized above. Open-ended questions were asked in interviews (75% of which were conducted in Spanish) to describe the processes participants underwent while becoming activated and empowered.

The study results show that patient activation and patient empowerment are interdependent. By applying Finfgeld’s empowerment model, the authors found that patient activation – as realized through RQP-MH – included the four stages of empowerment (participating, choosing, supporting, and negotiating).

Many participants enthusiastically embraced the RQP-MH strategy, a strong example of how this skill-building strategy challenges stereotypical models of Latinos as passive and deferential to authority in health care contexts. The authors conclude that RQP-MH improves patient-provider communication, a key first step in addressing disparities in health care quality.

Responses from participants when asked what they learned from the RQP-MH strategy:

“Just more direct, processing what I want to get out of the visit before going, setting goals, having questions I want to ask when I’m there. Making better use of my time, having a plan”

“The survey [training] helped me a lot explaining myself and getting my point across to let him know how I feel instead of letting him tell me how I feel…”

This article presents additional results from the study exploring a brief delivery of the RQI-developed patient activation intervention (PAI) in community health centers in New York City. Medical students delivered the 10-minute intervention to patients in the health center waiting rooms. Two evaluation measures were used:

Patient’s preference for control (PPC) scale: determines the degree to which patients wanted to be involved in their care

The PAI improved PAM scores regardless of their original PPC. One-third of the study participants moved from lower to higher levels of activation as determined by the PAM, with patients who began with lower levels of activation showing the greatest improvement. The PAI was determined to be efficient in its activation of low-income minority populations, priming them for more effective encounters with their physicians and establishing a precedent for patient activation initiatives in other community health center settings.

First-year medical students delivered a 10-minute patient activation intervention (PAI), developed by the Right Question Institute, to low-income, racial/ethnic minority patients of several community health centers in New York City. The PAI aimed to improve these patients’ communication with their physicians and to increase patient activation on the Patient Activation Measure®. The intervention was performed while patients waited to be seen by a physician and can be delivered by people with limited medical training. It included the following five steps:

Understanding decisions

Choosing a focus for the health care visit

Brainstorming questions

Identifying closed-ended and open-ended questions

Prioritizing questions

Overall, patients valued the PAI as a useful tool for engaging them in the physician-patient relationship. In addition, patients who received the PAI reported increased satisfaction with the healthcare that they received. The study also revealed several factors that influence the question-asking behavior of minority patients including patient attitudes, social factors, and patient’s self-efficacy in question formulation.

Quotes from participants:

I liked the fact that you pulled me to the side to reassure me that I was in charge as much as the doctor was or even more so.

The talk (PAI) gave me an extra push to ask what I need. I don’t feel nervous and intimidated.

I used to just be satisfied with a simple answer or whatever she (the physician) answered but this time I was able to get more information.

This article explores the use of decision aids (DA) and the RQI-developed Patient Activation Intervention (PAI) to improve patient activation. Lower SES populations are “less activated,” or less likely to ask questions, state their preferences, and take charge of their decisions. These groups may be less prepared to benefit from decision aids and may require additional strategies for increased activation. In this study, patients were categorized into control, PAI alone, DA alone, and DA + PAI groups to evaluate the impact of a decision aid video and the Patient Activation Intervention on two measures:

Patients’ Level of Activation as measured by the Patient Activation Measure (PAM)

According to the results, the DA alone changed DSE scores while the PAI and DA both changed PAM scores in the least activated patients. These findings show that the DA and PAI methods together are effective ways to increase level of activation and promote question-asking skills in patients who are least activated.

Better Questions, Better Decisions, and a Stronger Democracy

We’ve been at work for more than 20 years teaching a strategy that helps people in low-income communities learn to advocate for themselves and their families. We have seen people use the strategy to advocate for their children at school, participate in decisions that affect them at the welfare office, secure better job training opportunities, and partner more effectively with their healthcare providers. We’ve also seen that the same strategy has universal value and has been used by college and graduate school students, professors, and professionals in various fields.

What is the “Right Question Strategy?” It is deceptively simple: Teach just two skills; how to ask your own questions and how to participate in decisions that affect you. We are often challenged to explain why these simple skills even need to be taught, and then, there are times when those who understand the full significance of these very sophisticated skills need to be convinced that they can even be taught.

We are seeing an explosion of implementation around the country in teaching the skill of question formulation. Since Harvard Education Press published Make Just One Change: Teach Students to Ask Their Own Questions in 2011, thousands of educators around the world have begun to teach their students how to ask their own questions. The results are students who are more engaged in their learning, take more ownership and learn more.

Learning “just” these two skills creates not only a pathway to success on many levels but also a pathway to full participation in democracy. We need more people capable of thinking for themselves and ready to make a contribution to building a more democratic and more just world.